Babies and Children - Clinical Tree

Babies

A baby is a neonate for its first 4 weeks and an infant for its first year. Neonates are classified by gestational age or birthweight ( Box 15.1 ).

15.1

Classification of newborn infants

Birthweight

Extremely low birthweight (ELBW): <1000 g
Very low birthweight (VLBW): <1500 g
Low birthweight (LBW): <2500 g
Normal: ≥2500 g

Gestational age

Extremely preterm: <28 weeks
Preterm: <37 weeks (<259th day)
Term: 37–42 weeks
Post-term: >42 weeks (>294th day)

The history

Ask the mother and look in the maternal notes for relevant history:

Maternal history

Is there a family history of significant illness (e.g. diabetes, hereditary illnesses)? What were the outcomes of any previous pregnancies?

Pregnancy history

How was the maternal health in pregnancy? Did the mother take medications or other drugs?

What did any antenatal screening tests show?

Birth history

What was the birthweight, gestation at birth and mode of delivery? Was there prolonged rupture of the fetal membranes or maternal pyrexia? Was there a nonreassuring fetal status during delivery or meconium staining of the amniotic fluid? Was resuscitation required after birth? What were the Apgar scores ( Box 15.2 ) and the results of umbilical cord blood gas tests?

15.2

Apgar score

Add scores for each line; maximum score is 10. bpm, Beats per minute. Reproduced with permission: APGAR V, A proposal for a new method of evaluation of the newborn infant. Curr Res Anesth Analg . 1953;32(4):260–267.

Clinical score	0	1	2
Heart rate	Absent	≤100 bpm	>100 bpm
Respiratory effort	Absent	Slow and irregular	Good: strong
Muscle tone	Flaccid	Some flexion of arms and legs	Active movement
Reflex irritability	No responses	Grimace	Vigorous crying, sneeze or cough
Colour	Blue, pale	Pink body, blue extremities	Pink all over

Infant’s progress

Has the infant fed well? Has the infant passed meconium and urine since birth? In later infancy, what are the specific signs and systems and developmental progress, depending on the presenting problem?

Presenting problems and definitions

Infants cannot report symptoms, so you must recognise the presenting problems and signs of illness, which are nonspecific in young infants. Always take the concerns of parents seriously.

Pallor

Always investigate pallor in a newborn, as it implies anaemia or poor perfusion. Newborn infants have higher haemoglobin levels than older children and are not normally pale. Haemoglobin levels of less than 120 g/L (<12 g/dL) in the perinatal period are low. Preterm infants look red because they lack subcutaneous fat.

Respiratory distress

Respiratory distress is tachypnoea (respiratory rate) greater than 60 breaths per minute, with intercostal and subcostal indrawing, sternal recession, nasal flaring and the use of accessory muscles.

Cyanosis

Bluish discoloration of the lips and mucous membranes due to hypoxia is difficult to see in newborn infants unless oxygen saturation ( Sp O ₂ ) is less than 80% (normal is ≥95%). Causes include congenital heart disease and respiratory disease. Cyanosis always needs investigation (p. 30).

Acrocyanosis

Acrocyanosis is a bluish-purple discoloration of the hands and feet and is a normal finding, provided the newborn is centrally pink.

Jaundice

Many newborns develop jaundice in the days after birth. Look for yellow sclerae in newborns with coloured skin, or you may miss it. Examine the baby in bright normal light. Normal physiological jaundice cannot be distinguished clinically from jaundice from a pathological cause. Newborn infants with jaundice require a bilirubin measurement to assess the need for further investigation and possible treatment.

Jitteriness

Jitteriness is high-frequency tremor of the limbs and is common in term infants in the first few days. It is stilled by stimulating the infant and is not associated with other disturbance. If jitteriness is excessive, exclude hypoglycaemia, polycythaemia and neonatal abstinence syndrome (drug withdrawal). Infrequent jerks in light sleep are common and normal; regular clonic jerks are abnormal.

Dysmorphism

Identifying abnormal body structure (dysmorphism) is subjective because of human variability. Individual features may be minor and isolated or may signify a major problem requiring investigation and management. A recognisable pattern of several dysmorphic features together may indicate a ‘dysmorphic syndrome’ such as Down′s syndrome (p. 36). Use caution and sensitivity when discussing possible dysmorphism with parents of a newborn child.

Hypotonia

Hypotonia (reduced tone) may be obvious when you handle an infant. Term infants’ muscle tone normally produces a flexed posture at the hips, knees and elbows. Hypotonic infants may lack this flexion. Hypotonia can occur with hypoxia, hypoglycaemia or sepsis, or may be due to a specific brain, nerve or muscle problem. Preterm infants have lower tone than term infants and are less flexed.

Apgar score

This first clinical assessment of a neonate is made immediately after birth. Tone, colour, breathing, heart rate and response to stimulation are each scored 0, 1 or 2 (see Box 15.2 ), giving a maximum total of 10. Healthy neonates commonly score 8 to 10 at 1 and 5 minutes. The score predicts the need for, and efficacy of, resuscitation. A low score should increase with time; a decreasing score is a cause for concern. Persistently low scores at 10 minutes predict death or later disability. Neonates with scores of less than 8 at 5 minutes require continued evaluation until it is clear they are healthy.

The physical examination of newborns

Timing and efficacy of the routine neonatal examination

Examine a newborn with the parents present. There is no ideal time. If it is performed on day 1, some forms of congenital heart disease may be missed because signs have not developed. If it is delayed, some babies will present before the examination with illness that may have been detectable earlier. Approximately 9% of neonates have an identifiable congenital abnormality, but most are not serious. Always record your examination comprehensively to avoid problems if illness or physical abnormality is identified later. Fewer than half of all cases of congenital heart disease or congenital cataract are detected by newborn examination.

General examination

Examine babies and infants in a warm place on a firm bed or examination table. Have a system to avoid omitting anything, but avoid an overly rigid approach as you may be unable to perform key elements if you unsettle the baby. Do things that may disturb the baby later in the examination sequence.

Examination sequence

Observe whether the baby looks well and is well grown.
Look for:
- cyanosis
- respiratory distress
- pallor
- plethora (suggesting polycythaemia).
Note posture and behaviour.
Note any dysmorphic features.
Auscultate the heart and palpate the abdomen if the baby is quiet.
If the baby cries, does the cry sound normal?

Skin

Normal findings

The skin may look normal, dry, wrinkled or vernix covered in healthy babies. There may be meconium staining of the skin and nails.

Prominent capillaries commonly cause pink areas called ‘stork’s beak marks’ at the nape of the neck, eyelids and glabella ( Fig. 15.1 ). Facial marks fade spontaneously over months; those on the neck often persist. Milia (fine white spots) and acne neonatorum (larger cream-coloured spots) are collected glandular secretions and disappear within 2 to 4 weeks. Erythema toxicum is a common fleeting, blanching, idiopathic maculopapular rash of no consequence, affecting the trunk, face and limbs in the first few days after birth.

Abnormal findings

Document any trauma such as scalp cuts or bruising.

Dense capillary haemangiomas (port-wine stains) will not fade. Referral to a dermatologist is advisable as laser treatment may help in some cases. Around the eye, they may indicate Sturge–Weber syndrome (a facial port-wine stain with an underlying brain lesion, associated with risk of later seizures, cerebral calcification and reduced cognitive function). Melanocytic naevi require follow-up and treatment by a plastic surgeon or dermatologist. A Mongolian blue spot ( Fig. 15.2 ) is an area of bluish discolouration over the buttocks, back and thighs. Easily mistaken for bruising, it usually fades in the first year.

Subcutaneous fat necrosis causes palpable firm plaques, often with some erythema under the skin. If extensive, there can be associated hypercalcaemia that may require treatment. Blisters or bullae are usually pathological.

Head

Examination sequence

Note the baby’s head shape ( Box 15.3 ) and any swellings.

15.3

Neonatal head shapes

Head shape	Description
Microcephalic (small headed)	Small cranial vault
Megalencephalic (large headed)	Large cranial vault
Hydrocephalic (water headed)	Large cranial vault due to enlarged ventricles
Brachycephalic (short headed)	Flat head around the occiput
Dolichocephalic (long headed)	Head that looks long relative to its width
Plagiocephalic (oblique headed)	Asymmetrical skull

Feel the anterior fontanelle ( Fig. 15.3 ). Is it sunken, flat or bulging?
Palpate the cranial sutures.

Normal findings

Transient elongation of the head is common from moulding during birth. Caput succedaneum is soft-tissue swelling over the vertex due to pressure in labour. Overriding cranial sutures have a palpable step.

Abnormal findings

Cephalhaematoma is a firm, immobile, usually parietal swelling caused by a localised haemorrhage under the cranial periosteum. It may be bilateral, and periosteal reaction at the margins causes a raised edge. No treatment is required. Do not confuse this with the boggy, mobile, poorly localised swelling of subgaleal haemorrhage (beneath the flat sheet of fibrous tissue that caps the skull), which can conceal a large blood loss and is life-threatening if unrecognised.

Separated cranial sutures with an obvious gap indicate raised intracranial pressure. Rarely, the cranial sutures are prematurely fused (synostosis), producing ridging, and the head shape is usually abnormal. Abnormal head size requires detailed investigation, including neuroimaging.

Eyes

Examination sequence

Inspect the eyebrows, lashes, lids and eyeballs.
Gently retract the lower eyelid, and check the sclera for jaundice.
Test ocular movements and vestibular function:
Turn the newborn’s head to one side; watch as the eyes move in the opposite direction. These are called doll’s-eye movements (see Fig. 8.15, p. 165).
Hold the infant upright at arm’s length and move them in a horizontal arc. The infant should look in the direction of movement and have optokinetic nystagmus. This response becomes damped by 3 months.

Normal findings

Harmless yellow crusting without inflammation is common after birth in infants, due to narrow lacrimal ducts.

Term infants usually fix visually.

Abnormal findings

Eye infection gives a red eye and purulent secretions. An abnormal pupil shape is usually a coloboma (a defect in the iris inferiorly that gives the pupil a keyhole appearance, Fig. 15.4 ). This can also affect deeper structures, including the optic nerve, and lead to visual impairment. It can be associated with syndromes, as can microphthalmia (small eyeballs). Large eyeballs that feel hard when palpated through the lids suggest congenital glaucoma (buphthalmos).

Ophthalmoscopy

Examination sequence

Hold the baby in your arms. Turn your body from side to side, and the movement will encourage the baby to open their eyes.
Look at each pupil from about 20 cm through the ophthalmoscope. You should see the red reflex of reflected light from the retina.

Normal findings

Puffy eyes in the first days after birth impede the examination. If this happens, always examine again later because failure to detect and treat a cataract will cause permanent amblyopia.

Abnormal findings

An absent red reflex suggests cataract; refer to an ophthalmologist.

Nose

Examination sequence

Exclude obstructed nostrils (choanal atresia) by blocking each nostril in turn with your finger to check that the infant breathes easily through the other.

Mouth

Examination sequence

Gently press down on the lower jaw so that the baby will open the mouth.
Shine a torch into the mouth and look at the tongue and palate. If you need to use a tongue depressor to obtain a clear view of the palate, it should be a sterile single-patient use item.
Palpate the palate using your fingertip.

Normal findings

Epstein's pearls are small, white mucosal cysts on the palate that disappear spontaneously.
White coating on the tongue that is easily scraped off with a swab is usually curdled milk.

Abnormal findings

Ankyloglossia (tongue tie) is when the lingual frenulum joining the underside of the tongue to the floor of the mouth is so short that it interferes with feeding. It should not be diagnosed if feeding is satisfactory. A white coating on the tongue, which is not easily removed and may bleed when scraped, is caused by Candida albicans (thrush). Macroglossia (a large protruding tongue) occurs in Beckwith–Wiedemann syndrome. A normal-sized tongue protrudes through a small mouth in Down′s syndrome (glossoptosis).

Cleft palate may involve the soft palate or both hard and soft palates. It can be midline, unilateral or bilateral and may also involve the gum (alveolus). Cleft lip can appear in isolation or in association with it. Refer affected infants early to a specialist multidisciplinary cleft team. Micrognathia (a small jaw) is sometimes associated with cleft palate in the Pierre Robin syndrome, with posterior displacement of the tongue and upper airway obstruction.

A ranula is a mucous cyst on the floor of the mouth that is related to the sublingual or submandibular salivary ducts. Congenital ranulas may resolve spontaneously but sometimes require surgery.

Teeth usually begin to erupt at around 6 months but can be present at birth.

Ears

Examination sequence

Note the size, shape and position.
The helix should attach above an imaginary line around the head, level with the inner corners of the eyes.
Check that the external auditory meatus looks normal.

Normal findings

The helix can be temporarily folded due to local pressure in utero.
Preauricular skin tags do not require investigation.

Abnormal findings

Abnormal ear shape and position is a feature of some syndromes.

Neck

Examination sequence

Inspect the neck for asymmetry, sinuses and swellings.
Palpate any masses. Use ‘SPACESPIT’ (see Chapter 3 , p. 34) to interpret your findings.
Transilluminate swellings. Cystic swellings glow, as the light is transmitted through clear liquid. Solid or blood-filled swellings do not.

Normal findings

One-third of normal neonates have palpable cervical, inguinal or axillary lymph nodes. Neck asymmetry is often due to fetal posture and usually resolves.

Abnormal findings

A lump in the sternocleidomastoid muscle (sternomastoid ‘tumour’) is caused by a fibrosed haematoma with resultant muscle shortening. This may produce torticollis, with the head turned in the contralateral direction. Refer for physiotherapy.

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